2010 American Heart Association

essential bridge between BLS and long-term survival with good
neurologic function.
In terms of airway management the 2010 AHA Guidelines
for CPR and ECC have a major new Class I recommendation
for adults: use of quantitative waveform capnography for
confirmation and monitoring of endotracheal tube placement.
In addition, the use of supraglottic advanced airways continues
to be supported as an alternative to endotracheal intubation
for airway management during CPR. Finally, the routine
use of cricoid pressure during airway management of patients
in cardiac arrest is no longer recommended.
There are several important changes in the 2010 AHA
Guidelines for CPR and ECC regarding management of
symptomatic arrhythmias. On the basis of new evidence of
safety and potential efficacy, adenosine can now be considered
for the diagnosis and treatment of stable undifferentiated
wide-complex tachycardia when the rhythm is regular and the
QRS waveform is monomorphic. For symptomatic or unstable
bradycardia, intravenous (IV) infusion of chronotropic
agents is now recommended as an equally effective alternative
to external pacing when atropine is ineffective.
For 2010 a new circular AHA ACLS Cardiac Arrest Algorithm
has been introduced as an alternative to the traditional
box-and-line format. Both algorithms represent restructured and
simplified formats that focus on interventions that have the
greatest impact on outcome. To that end, emphasis has been
placed on delivery of high-quality CPR with minimal interruptions
and defibrillation of VF/pulseless VT. Vascular access,
drug delivery, and advanced airway placement, while still
recommended, should not cause significant interruptions in chest
compression or delay shocks. In addition, atropine is no longer
recommended for routine use in the management of pulseless
electrical activity (PEA)/asystole.
Real-time monitoring and optimization of CPR quality
using either mechanical parameters (eg, monitoring of chest
compression rate and depth, adequacy of chest wall relaxation,
length and duration of pauses in compression and
number and depth of ventilations delivered) or, when feasible,
physiologic parameters (partial pressure of end-tidal CO 2
[PETCO 2], arterial pressure during the relaxation phase of
chest compressions, or central venous oxygen saturation
[ScvO 2]) are encouraged. When quantitative waveform capnography
is used for adults, guidelines now include recommendations
for monitoring CPR quality and detecting ROSC
based on PETCO 2 values.
Finally the 2010 AHA Guidelines for CPR and ECC continue
to recognize that ACLS does not end when a patient
achieves ROSC. Guidelines for post–cardiac arrest management
have been significantly expanded (see Part 9) and
now include a new Early Post–Cardiac Arrest Treatment
Algorithm.
Post–Cardiac Arrest Care
The 2010 AHA Guidelines for CPR and ECC recognize the
increased importance of systematic care and advancements in
the multispecialty management of patients following ROSC
and admission to the hospital that can affect neurologically
intact survival. Part 9: “Post–Cardiac Arrest Care” recognizes
the importance of bundled goal-oriented management and
Field et al Part 1: Executive Summary S645
interventions to achieve optimal outcome in victims of
cardiac arrest who are admitted to a hospital following
ROSC. We recommend that a comprehensive, structured,
integrated, multidisciplinary system of care should be implemented
in a consistent manner for the treatment of post–
cardiac arrest patients.
Initial and later key objectives of post–cardiac arrest care
include
● Optimizing cardiopulmonary function and vital organ perfusion
after ROSC
● Transportation to an appropriate hospital or critical-care
unit with a comprehensive post–cardiac arrest treatment
system of care
● Identification and intervention for acute coronary syndromes
(ACS)
● Temperature control to optimize neurologic recovery
● Anticipation, treatment, and prevention of multiple organ
dysfunction
The primary goal of a bundled treatment strategy for the
patient after cardiac arrest includes a consistently applied
comprehensive therapeutic plan delivered in a multidisciplinary
environment leading to the return of normal or
near-normal functional status. Patients with suspected ACS
should be triaged to a facility with reperfusion capabilities
and a multidisciplinary team prepared to monitor patients for
multi-organ dysfunction and initiate appropriate post–cardiac
arrest therapy, including hypothermia. Prognostic assessment
in the setting of hypothermia is changing, and experts
qualified in neurologic assessment in this patient population
and integration of prognostic tools are essential for patients,
caregivers, and families and are reviewed in detail in Part 9.
As a guide to therapy, a new algorithm and a table of
integrated goal therapy care were developed.
Stabilization of the Patient With ACS
The 2010 AHA Guidelines for CPR and ECC recommendations
for the evaluation and management of ACS have been
updated to define the scope of training for healthcare providers
who treat patients with suspected or definite ACS within
the first hours after onset of symptoms. Within this context
several important strategies and components of care are
defined and emphasized by these guidelines and include
systems of care for patients with ST-elevation myocardial
infarction (STEMI), prehospital 12-lead electrocardiograms
(ECGs), triage to hospitals capable of performing percutaneous
coronary intervention (PCI), and comprehensive care for
patients following cardiac arrest with confirmed STEMI or
suspected ACS.
A well-organized approach to STEMI care requires integration
of community, EMS, physician, and hospital resources
in a bundled STEMI system of care. An important
and key component of STEMI systems of care is the
performance of prehospital 12-lead ECGs with transmission
or interpretation by EMS providers and advance notification
of the receiving facility. Use of prehospital 12-lead ECGs has
been recommended by the AHA Guidelines for CPR and ECC
since 2000 and has been documented to reduce time to
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